Enhanced CPD DO C
Reena Wadia
An Update on Halitosis:
Seven Common Questions
Abstract: The aim of this review is to summarize answers to common questions related to halitosis including its prevalence, the different
types, aetiology, assessment, diagnosis and management in general practice.
CPD/Clinical Relevance: Halitosis is common, and dental professionals are often responsible for its diagnosis and management.
Dent Update 2021; 48: 459–462
Oral healthcare professionals should be
aware of the fundamentals of halitosis
as they are primarily responsible for its
diagnosis and management.
1. What is halitosis?
Halitosis (from the Latin for breath,
halitus and the Greek suffix osis, meaning
abnormal)1 is the presence of unpleasant or
offensive breath odour independent of its
origin. Halitosis can have major detrimental
social implications for an individual
and can significantly impact on normal
social interactions.2
2. How common is halitosis?
The true prevalence of halitosis is unknown.
The majority of epidemiological studies
are difficult to evaluate as they are largely
based on subjective self-estimation of
halitosis, which is known to be limited by
inaccuracy and low sensitivity. However, the
Reena Wadia, BDS Hons (Lond) MJDF
RCS (Eng) MClinDent (Perio) MPerio RCS
(Edin) FHEA, Principal and Specialist
Periodontist at RW Perio, London.
Associate Specialist at King's College
Hospital University NHS Trust, London.
email: reena@rwperio.com
June 2021 DentalUpdate 459
available evidence suggests that halitosis
is common, and can affect individuals of
all ages.
The prevalence of persistent halitosis
in one of the most recent studies was
reported to be 15%, was nearly three times
higher in men than in women (regardless
of age) and the risk was slightly more than
three times greater in individuals over 20
years of age compared with those aged 20
years or under, controlling for gender.3 The
methodology used was interesting because
it overcame the limitations of self-reporting
of halitosis, while retaining its subjective
judgement; the design also facilitated the
recruitment of large numbers of subjects.
Overall, the majority of studies report
that approximately 30% of people have
halitosis,4–6 but some studies do estimate
that more than 50% of the population
have halitosis.7
3. What are the different
types of halitosis?
Intra-oral halitosis is also known as oral
malodour and describes cases where the
source of halitosis lies within the mouth.
Extra-oral halitosis is where the source of
halitosis lies outside the mouth. This can be
further subdivided into blood-borne and
non-blood-borne halitosis.8 Pseudo-halitosis
and halitophobia are used to describe
patients who think or persist in believing
Periodontics
they have halitosis, even after professional
assessment and a diagnosis that they do
not have halitosis. Temporary, or transient
halitosis, as well as morning bad breath are
other forms of halitosis.
4. What is the aetiology
and pathogenesis of
intra‑oral halitosis?
In about 85% of patients with persistent
genuine halitosis, the odour originates
from the mouth.9 The aetiology of intra-
oral halitosis is primarily a tongue coating
(Figure 1) and to a lesser extent gingivitis/
periodontitis (Figure 2) or a combination of
these.10 A number of other acute conditions
can cause malodour including pericoronal
infections, oral ulceration, acute herpetic
gingivostomatitis and necrotizing gingivitis,
all of which produce a characteristic strong
'fetor oris'. The presence of xerostomia,
candidal infections, medications,
overhanging restorations and caries may
also contribute to intra-oral halitosis.10–13
Intra-oral halitosis arises from the
production of volatile malodorous
compounds by the action of bacteria in
breaking down components of epithelial
cells, salivary and serum proteins, and
food debris.
A wide range of molecular species are
able to contribute to the overall production
of malodour. Notably, much attention has
 Periodontics
Figure 1. Tongue coating.
Figure 2. Periodontitis: the patient’s presenting
complaint was ‘bad breath’.
been given to volatile sulphur compounds,
including methyl mercaptan, hydrogen
sulphide and dimethyl sulphide. However,
a number of other compounds may also
contribute to malodour (Table 1).14–16
The production of these compounds is
mediated by the putrefaction of debris and
protein substrates by a wide range of oral
anaerobic bacteria (Table 2), particularly
those which exhibit proteolytic activity.17–20
In the case of volatile sulphur compound
generation, bacteria act on the sulphur-
containing amino acids cysteine, cystine
and methionine, which are available
following proteolysis.
The dorsum of the tongue provides
a suitable environment for the growth of
anaerobic organisms, as favourable redox
potentials are found in the deep crypts of
the tongue associated with the structure
of the tongue papillae.2 Tongue coatings
include desquamated epithelial cells,
food debris, bacteria and salivary proteins
and provide an ideal environment for the
generation of volatile sulphur compounds
and other compounds that contribute to
malodour.2 Studies suggest that malodour
may be associated with total bacterial load
of Gram-negative anaerobes, both in saliva
and in tongue coatings.21–24 The extent
460 DentalUpdate June 2021
Volatile sulphur compounds
Diamines
Phenyl compounds
Table 1. Volatile molecules contributing to intra-oral halitosis.
Porphyromonas gingivalis
Prevotella intermedia
Treponema denticola
Fusobacterium nucleatum
Tannerella forsythensis
Porphyromonas endodontalis
Eubacterium species
Table 2. Micro-organisms associated with
intra‑oral halitosis.
of tongue coating can vary considerably
between individuals, and may be increased
in patients with periodontitis and in
response to systemic upset.
These anaerobic bacteria are also
associated with subgingival plaque
in periodontitis, and indeed, high
concentrations of volatile sulphur
compounds are present in periodontal
pockets, and in gingival crevicular fluid of
those with gingivitis or periodontitis.
5. What are the causes of the
other types of halitosis?
Extra-oral halitosis is far less frequent than
intra-oral halitosis and originates from
pathological conditions outside the mouth.
In non-blood-borne extra-oral halitosis,
these may include nasal, paranasal and
laryngeal regions, lungs or upper digestive
tract. In the case of a blood-borne extra-
oral halitosis, the malodour is emitted via
the lungs and originates from disorders
anywhere in the body, for example due to
hepatic cirrhosis.10 Table 3 summarizes the
common extra-oral causes of halitosis.25
Transient halitosis may be caused by
tobacco use, garlic and some spicy foods,
and by alcohol. Morning bad breath is
caused by the decrease in saliva production
during the night, ie lack of the natural
cleaning mechanism.10 It is common on
waking in many people, but is usually short
Methyl mercaptan, hydrogen sulphide
and dimethyl sulphide
Putrescine, cadaverine
Short-chain fatty acids
Butyric acid, propionic acid
Indole, skatole, pyridine
lived and typically resolves shortly after
rising, especially after eating breakfast
and performing morning oral
hygiene procedures.2
6. How do you assess and
diagnose halitosis?
A thorough medical history questionnaire,
soft tissue examination to check for a
tongue coating, periodontal examination
and an organoleptic assessment will
form the key steps in making a diagnosis
in practice.
In terms of the organoleptic assessment
of exhaled air, the clinician sniffs the air
exhaled from the mouth, as well as the
nose.26 Smelling both nose and mouth
air is important as halitosis detectable
from the nose alone (asking the patient to
breathe while the mouth is closed) is likely
to come from the nose or the sinuses, or
from respiratory or gastrointestinal tracts.
At its simplest, a clinician may use their own
judgement to decide on the presence or
absence of malodour in a patient. In clinical
investigations, trained breath assessors may
assess exhaled air from subjects, scoring
their assessments on a 6-point scale from
0 to 5, according to the assessed severity
of the condition.27 As a general rule in
practice, it is advisable that the patient
abstains from eating odoriferous foods for
48 hours before the assessment, and that
both the patient and the examiner refrain
from drinking coffee, tea or juice, smoking
and using scented cosmetics before the
assessment.28 More objective measurements
of halitosis are available, but they are rarely
used in routine clinical practice as they are
expensive and time-consuming.
Gas chromatography can precisely
measure specific gases. However, traditional
forms need inert column carrier gas and

Respiratory system (microbial aetiology)
Gastrointestinal tract
Metabolic disorders (blood-borne)
Drugs (blood-borne)
Table 3. Extra-oral causes of halitosis.
require technicians or specialists with
adequate training, and are thus clinically
impractical.29 However, a newly developed
portable gas chromatograph (OralChroma,
Abi-medical, Abilit Corp, Osaka, Japan)
has now been described,30 which does not
use a special carrier gas (using air instead)
and is highly sensitive, yet relatively low
in cost compared with a standard gas
June 2021 DentalUpdate 461
Sinusitis
Antral malignancy
Cleft palate
Foreign bodies in the nose
Nasal malignancy
Tonsilloliths
Tonsillitis
Pharyngeal malignancy
Lung infections
Bronchitis
Bronchiectasis
Lung malignancy
Oesophageal diverticulum
Gastro-oesophageal reflux disease
Malignancy
Acetone-like smell in uncontrolled diabetes
Uraemic breath in renal failure
Fetor hepaticus in liver disease
Trimethylaminuria (fish odour syndrome)
Hypermethioninaemia
Cystinosis
Amphetamines
Chloral hydrate
Cytotoxic agents
Dimethyl sulphoxide
Disulfiram
Nitrates and nitrites
Phenothiazines
Solvent abuse
chromatograph. Suphide monitoring is an
easily used method, but has the limitation
that important odours are not detected. An
example of this is the halimeter (Interscan
Corp, Chatsworth, CA, USA).
The scientific and practical value of
alternative measurement methods, such
as the BANA (benzoyl–arginine–naphthyl–
amide) test, chemical sensors, the salivary
Periodontics
incubation test, quantifying β-galactosidase
activity, ammonia monitoring, the ninhydrin
method and the polymerase chain reaction,
have yet to be fully established.31,32
If no halitosis can be found during the
initial examination, the assessment can be
repeated on two or three different days.
Thereafter, if halitosis is still not present,
but the patient feels they are suffering
from it, the patient can be diagnosed with
pseudo-halitosis – a diagnosis that can be
supported by established questionnaires.28
7. What are the recommended
steps in managing
halitosis in practice?
The management of halitosis depends
largely on the cause. Once the diagnosis of
intra-oral halitosis has been confirmed, the
clinician should:
1. Provide personalized advice on
halitosis, including a discussion on
its aetiology for that specific patient.
Emphasis on the importance of
the person's own self-care for the
improvement of the condition should
be emphasized. Reassurance that
treatment can improve and eliminate
the halitosis is often helpful.
2. Advise the patient to avoid smoking
and minimize foods that might be
responsible for halitosis.
3. Advise the patient to keep their
mouth as moist as possible by staying
hydrated and chewing sugar-free
chewing gum.
4. Optimize the patient's oral
hygiene regimen, including twice-
daily tooth brushing and daily
interdental cleaning.
5. Instruct and motivate the patient
to use of a tongue cleaning device
when a tongue coating is present.
Tongue cleaning is an evidence-
based technique effective in reducing
intra-oral halitosis caused by a
tongue coating.33
6. Recommend the use of chemical
agents with proven efficacy, if
required. Mouth rinses and dentifrices
with active ingredients that have
been shown to have a significantly
beneficial effect include: chlorhexidine,
cetylpyridinium chloride and zinc
combinations.33 If mouth rinses
are used these should be used at a
 Periodontics
different time to toothbrushing.
7. Provide periodontal therapy if the
patient is suffering from gingivitis
or periodontitis. Address any other
oral conditions that may play a role,
if appropriate.
8. Address local dental factors if present,
such as overhanging restorations
and caries.
9. Following appropriate therapy, review
the status of the halitosis and suggest
further steps if not resolved.
It is important to be aware that a limited
number of patients with extra-oral halitosis
and halitophobia (<10% together) will need
to be referred to an appropriate medical
professional.10 This may involve an oral
medicine opinion, an otorhinolaryngologist
to rule out the presence of chronic tonsillitis
or chronic sinusitis, a physician to rule out
gastric, hepatic, endocrine, pulmonary
or renal disease, or a psychologist
or psychiatrist.
Compliance with Ethical Standards
Conflict of Interest: The author has
produced her own metal tongue scraper
called the RW Perio Tongue Scraper, which
she sells at her clinic and online.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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